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I Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. E ` vICE USE: APPLICATION (For Non-Transferable, Revocable,Suspendable) ENVIRONMENTAL HEALTH PERMIT PUMP& ELL ' (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is ' made in compliance with SJoaquin Count Ordinance No. 1882 and the rules and regulations of the San aquioral Health District. Exact Site Address irf i N• BeecherCitylTown ��ockon Owner's Name Tom Hibbard JD -eherPhone 93I_-_1T7 2 i Bee Address , City OC AI'l Contractor's Name aC a o, Moe License# Buy s P' ye I Contractor's Address 24y N• acOrifi, OC OTl Emergency Phone e � r Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No 1 TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPA IRE] REPL-ACEMEN_T t5)1, 6 t %,DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Sewage Disposal Field -Cesspool/Seepage Pitother I Property Line Private Domestic Well Public Domestic Well i INTENDED USE TYPE OF WELL ❑ INDUSTRIAL , ❑ CABLE TOOL Dia: of Well Excavation ;n'bOMESTIC/PRIVATE_' ❑ DRILLED Dia. of Well Casing ❑�DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ,.[]..CATHODIC PROTECTION ❑ ROTARY Type of Grout �O.DISPOSAL --[].OTHER,- -- - _ -Other Information '❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor E \�F Types Pump_ H,P. PUMP REPLACEMENT: �`5tate_Work_pone 'eplac-edpUmp� PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter pp Aroximate Depth '1 F a ,Describe Material and Procedure , 'J P I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin C6unty ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhicl{,this permit is issued„I-Shall employ persons subject to workman's compensation laws of California.” R 3 I will c for a Grout I e ion prior t grouling and a final inspection. Signed X Title: G / Date: �!ii��1�" v � a (Draw Plot Plan on even rse Side) � , i ORD PARTMENT USE ONLY PHASE I Application Accepted ByDat dd: e � -:Jj Additional Comments: Phase II Grout Inspection phase final Inspection i Inspection By Date I. s ection B Datea/7 AR Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Re ived By July 31 BASE EXPLANATION BILLING { REMITTANCES $ REMIT 1 AMOUNTDUE GIIECKEt7 DATE '� DATE i REMITTED AMOUNT 1, FEELESS PRORATION PLUS I PENALTY OTHER I OTHER p . � Received by. Date Receipt No. Pefm,t No. Issuance Date, Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.14AZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 , f